PATIENT FINANCIAL RESPONSIBILITY FORM

5490 Bryson Drive, Suite 201 Naples, FL 34109

Phone: 239-431-5884 Fax (239) 631-6907

PATIENT FINANCIAL RESPONSIBILITY FORM

1. INDIVIDUAL'S FINANCIAL RESPONSIBILITY

? I understand that I am financially responsible for my health insurance deductible, coinsurance or noncovered service.

? Co-payments are due at time of service. ? If my plan requires a referral, I must obtain it prior to my visit. ? In the event that my health plan determines a service to be "not payable", I will be responsible for the

complete charge and agree to pay the costs of all services provided. ? If I am uninsured, I agree to pay for the medical services rendered to me at time of service. ? If you are scheduled for an ultrasound appointment and do not show there will be a $75 charge to

your account.

2. INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS I hereby authorize and direct payment of my medical benefits to Vascular Center of Naples on my behalf for any

services furnished to me by the providers.

3. AUTHORIZATION TO RELEASE RECORDS I hereby authorize Vascular Center of Naples to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider.

4. MEDICARE REQUEST FOR PAYMENT I request payment of authorized Medicare benefits to me or on my behalf for any services furnished me by or in Vascular Center of Naples. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services. Signature of Patient, Authorized Representative or Responsible Party Date Print Name of Patient, Authorized Representative or Responsible Party Relationship to Patient

______________________________________________________________ Signature of Patient, Authorized Representative or Responsible Party

____________________ Date

______________________________________________________________ Print Name of Patient, Authorized Representative or Responsible Party

____________________ Relationship to Patient

5490 Bryson Drive, Suite 201 Naples, FL 34109

Phone: 239-431-5884 Fax (239) 631-6907

Patient Demographic Information

_______________________________________________________________________

(Last Name)

(First Name)

(Middle Initial)

Address: ____________________________________________________________________________ City: _______________________________ State: _______________________ Zip: ________________

Phone: ___________________ Cell:____________________________ SSN:________________________

May we contact you/leave a message by phone: Yes _____ No _____

May we leave a message with a family member, if so please write name: ______________________________

May we contact you/leave a message by text: Yes _____ No _____

May we contact you/leave a message by email: Yes ____ No ____

Email: _____________________________

Date of Birth: ______________________ Height: ______ Weight: ______ Male Female

Ethnicity Origin or Race:

Hispanic or Latino Asian / Pacific Islander

Black or African American White

Native American or American Indian Other: _________

Marital Status: Married

Single

Widowed

Separated

Divorced

Person to contact in case of emergency: _____________________________________________________ Relation to Patient: ________________________________________ Phone: ______________________ List any person whom we can give health information to on your behalf: _____________________________________________ ___________________________________________________________________________________________________________ Referring Physician: _______________________________________ Phone:____________________ Primary Care Physician: ____________________________________ Phone: ___________________

Employer Name: __________________________________________ Phone:____________________

Type of Insurance:

Medicare

Medicaid

Group Workman's Comp

Other: ________

Name of Insurance: __________________________________________________________________

Policy Number: __________________________ Group Number: ___________________________

Name of Secondary Insurance: _________________________________________________________

Policy Number: __________________________ Group Number: ___________________________

Primary State of Residence (if Medicare): ___________________________

Is your condition a result of an accident? Yes

No

Date of injury if applicable: _________________ Adjuster: _______________________________

How did you hear about us?_____________________________________________________________________________________

_________________________________________________ Patient Signature

________________________ Date

5490 Bryson Drive, Suite 201 Naples, FL 34109

Phone: 239-431-5884 Fax (239) 631-6907

Patient Medical History

_______________________________________________________________________

(Last Name)

(First Name)

(Middle Initial)

Have you had or do you have any of the following conditions?

Anemia Arthritis Autoimmune Disorder Bleeding/Clotting Disorder Cancer Heart Disease Deep Vein Thrombosis Diabetes Sleep Disorder Varicose Veins

Drugs/Alcohol Thyroid Disease Gastrointestinal Disease Bladder/Urinary Problems Hyperlipidemia High Blood Pressure Infectious Disease Kidney Disease Stroke/TIA Vascular Disease

Neurological Disorder Osteoporosis/Osteopenia Pacemaker/Implantable Defibrillator Pregnancy Psychological Disorder Pulmonary Disease Pulmonary Embolism Restless Leg Syndrome Ulcers Vision Problems

Surgical History: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Allergies: _________________________________________________________________________________

Reaction:_________________________________________________________________________________

Medication Inventory

Name of Medication

Dosage

Frequency

Reason for Medication

I don't take any medications, vitamins, supplements, or any medicinal products of any kind.

5490 Bryson Drive, Suite 201 Naples, FL 34109

Phone: 239-431-5884 Fax (239) 631-6907

AUTHORIZATION FOR THE RELEASE OF MEDICAL RECORDS

To: Fax: Phone:

I, __________________________________________hereby authorize the release of any and all of my medical (Patient Name and Date of Birth)

records (including any and all HIV/AIDS records, alcohol and/or substance abuse records, and psychiatric and/or psychotherapeutic records.)

Information to be released to: Russell W. Becker, DO, FACOS, RPVI 5490 Bryson Drive, Suite 201 Naples, FL 34109 Fax (239) 631-6907

I request that copies of my medical record be made and mailed or delivered in a timely manner to the above address or fax number. I do hereby agree to hold Vascular Center of Naples, its agents and staff members free and harmless from any actions by it or them for alleged invasion of privacy, liable or slander, or defamation, arising in connection with the disclosure of such information.

_________________________________________________ Patient Signature

_____________________ Date

5490 Bryson Drive, Suite 201 Naples, FL 34109

Phone: 239-431-5884 Fax (239) 631-6907

NOTICE OF PRIVACY PRACTICES

Vascular Center of Naples 5490 Bryson Dr Suite 201

Naples, FL 34109

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our office.

TABLE OF CONTENTS

A. How This Medical Practice May Use or Disclose Your Health Information B. When This Medical Practice May Not Use or Disclose Your Health Information C. Your Health Information Rights

1. Right to Request Special Privacy Protections 2. Right to Request Confidential Communications 3. Right to Inspect and Copy 4. Right to Amend or Supplement 5. Right to an Accounting of Disclosures 6. Right to a Paper or Electronic Copy of this Notice D. Changes to this Notice of Privacy Practices E. Complaints

How This Medical Practice May Use or Disclose Your Health Information

This medical practice collects health information about you and stores it in a electronic health record. This is your medical record. The medical record is the property of this medical practice, but the information in the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:

1. Treatment. We use medical information about you to provide your medical care. We disclose medical information to our employees and others who are involved in providing the care you need. For example, we may share your medical information with other physicians or other health care providers who will provide services that we do not provide. Or we may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test. We may also disclose medical information to members of your family or others who can help you when you are sick or injured, or after you die.

2. Payment. We use and disclose medical information about you to obtain payment for the services we provide. For example, we give your health plan the information it requires before it will pay us. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.

3. Health Care Operations. We may use and disclose medical information about you to operate this medical practice. For example, we may use and disclose this information to review and improve the quality of care we provide, or the competence and qualifications of our professional staff. Or we may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for medical reviews, legal services and audits, including fraud and abuse detection and compliance programs and business planning and management. We may also share your medical information with our "business associates," such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information. We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts. We may also share medical information about you with the other health care providers, health care clearinghouses and health plans that participate with us in "organized health care arrangements" (OHCAs) for any of the OHCAs' health care operations. OHCAs include hospitals, physician organizations, health plans, and other entities which collectively provide health care services.

4. Appointment Reminders. We may use and disclose medical information to contact and remind you about appointments. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.

5. Sign In Sheet. We may use and disclose medical information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.

6. Notification and Communication With Family. We may disclose your health information to notify or assist in notifying a family member, your personal representative or another person responsible for your care about your location, your general condition or, unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the opportunity to

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